The long-term course of shoulder complaints: a prospective study in general practice.

OBJECTIVE: Assessment of the long-term course of shoulder complaints in patients in general practice with special focus on changes in diagnostic category and fluctuations in the severity of the complaints. DESIGN: Prospective descriptive study. SETTING: Four general practices in The Netherlands. METHOD: All patients (101) with shoulder complaints seen in a 5 month period were included. Assessment took place 26 weeks and 12-18 months after inclusion in the study with a pain questionnaire and a physical examination. RESULTS: A total of 51% of the patients experienced (mostly recurrent) complaints after 26 weeks and 41% after 12-18 months. Diagnostic changes were found over the course of time, mostly from synovial disorders towards functional disorders of the structures of the shoulder girdle, but also the other way round. Although 52 of the 101 patients experienced complaints in week 26, 62% of those patients considered themselves 'cured'. After 12-18 months, 51% of the 39 patients experiencing complaints felt 'cured'. CONCLUSION: Many patients seen with shoulder complaints in general practice have recurrent complaints. The nature of these complaints varies considerably over the course of time, leading to changes in diagnostic category. Because of the fluctuating severity of the complaints over time, feeling 'cured' or not 'cured' is also subject to change over time.

[Shoulder complaints in family practice; a simple approach]. / Schouderklachten in de huisartspraktijk: een simpele strategie.

In two patients with shoulder complaints, a man aged 56 years and a woman aged 43, the function of the shoulder girdle (structures of the cervical spine, the upper thoracic spine and the upper ribs) played an important role. A simple classification of shoulder complaints is presented in which the influence of the shoulder girdle is recognized: (a) synovial disorder: complaints originating from the structures of the glenohumeral joint, the subacromial space, the acromioclavicular joint or combinations of these, (b) shoulder girdle disorder: the complaints are caused by functional problems in the structures of the shoulder girdle, (c) combination disorder: both a synovial disorder and a functional disorder of the structures of the shoulder girdle are causing the complaints, making it impossible to determine which structure is the primary cause. Considering the limited therapeutic choices (at first nonsteroidal antiinflammatory drugs, followed in case of persistent complaints by injections of analgesics and corticosteroids for synovial complaints, or manipulative therapy for shoulder girdle complaints), a more detailed classification is not needed to determine a successful therapeutic strategy.

Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study.

OBJECTIVE: To compare the efficacy of physiotherapy, manipulation, and corticosteroid injection for treating patients with shoulder complaints in general practice. DESIGN: Randomised, single blind study. SETTING: Seven general practices in the Netherlands. SUBJECTS: 198 patients with shoulder complaints, of whom 172 were divided, on the basis of physical examination, into two diagnostic groups: a shoulder girdle group (n = 58) and a synovial group (n = 114). INTERVENTIONS: Patients in the shoulder girdle group were randomised to manipulation or physiotherapy, and patients in the synovial group were randomised to corticosteroid injection, manipulation, or physiotherapy. MAIN OUTCOME MEASURES: Duration of shoulder complaints analysed by survival analysis. RESULTS: In the shoulder girdle group duration of complaints was significantly shorter after manipulation compared with physiotherapy (P < 0.001). Also the number of patients reporting treatment failure was less with manipulation. In the synovial group duration of complaints was shortest after corticosteroid injection compared with manipulation and physiotherapy (P < 0.001). Drop out due to treatment failure was low in the injection group (17%) and high in the manipulation group (59%) and physiotherapy group (51%). CONCLUSIONS: For treating shoulder girdle disorders, manipulation seems to be the preferred treatment. For the synovial disorders, corticosteroid injection seems the best treatment.

Physical examination of the cervical spine and shoulder girdle in patients with shoulder complaints.

OBJECTIVE: To look for differences in mobility in randomly selected patients without shoulder complaints depending on age, gender and left- or right-handedness; to investigate in the patient group whether specific differences exist, depending on the diagnosis made or the afflicted side; and to detect differences between the findings on the mobility examination of the cervical and cervicothoracic spine in patients with shoulder complaints compared with the healthy population. DESIGN: Comparative study. METHOD: The physical examination findings after inclusion and after 26 wk of 101 shoulder patients were compared with those of 75 randomly selected patients without shoulder complaints and adjusted for age and gender. RESULTS: In the population of patients without shoulder complaints, the mobility in the cervical and upper thoracic spine was found to decrease with aging. Significant differences were found between the healthy and the afflicted population at the time of inclusion as well as after 26 wk, even though the majority of patients felt cured at that time. With all types of shoulder complaints, functional disorders in the shoulder girdle were found in which, at the time of inclusion, the emphasis was on pain and, after 26 wk, on restricted motion. Thus, functional disorders in the cervical spine, the higher thoracic spine and the adjoining ribs are not extrinsic causes of shoulder complaints, but an integral part of the intrinsic causes of shoulder complaints. CONCLUSION: Further study is needed to determine if this finding explains the high recurrence rate of shoulder complaints. It may be advisable to include the treatment of functional disorders of the shoulder girdle in treatment of patients with shoulder complaints.

The course of pain and the restriction of mobility in patients with shoulder complaints in general practice.

The objective of this research was to study the course of the pain and the restriction of mobility of the scapulohumeral joint (ROM) over time, and the factors influencing it, in patients with shoulder complaints in general practice. A total of 101 patients participated in this 25-week follow-up study. For the first 2 weeks, a non-steroidal anti-inflammatory drug (NSAID) was prescribed, after that period the physician could follow his usual therapeutic approach. The NSAIDs prescribed during the first 2 weeks resulted in a rapid decrease in the pain and the ROM. The group with the most severe pain consumed the most tablets, which resulted in a significant decrease in the pain and the ROM. It appeared that the course of the pain from week 2 to week 8 was significantly influenced by pain at inclusion, diagnosis and therapy. The most rapid decrease in the ROM appeared in the first 2 weeks. At week 0 and week 2, differences, in the ROM were seen in the subgroups for diagnosis pain score and age. The pain and the ROM showed most decrease in the first weeks. After 6 weeks hardly any changes were seen in the pain score and the ROM score. The margin of the pain score and the ROM score between the "cured" and the "not cured" patients was a very narrow one.

Classification of shoulder complaints in general practice by means of cluster analysis.

OBJECTIVE: To determine if a classification of shoulder complaints in general practice can be made with a cluster analysis of variables of medical history and physical examination. METHOD: One hundred one patients with shoulder complaints were examined upon inclusion (week 0) and after 2 weeks. Eleven variables of the medical histories and 19 variables of the physical examinations were used for the analysis. RESULTS: The analyses of week 0 and week 2 reveal three stable clusters: one cluster with almost half of the patients who hardly had limitations in the range of scapulohumeral mobility (ROM), one cluster with a small number of patients with a short history of complaints and a limitation of scapulohumeral mobility in all directions (7 and 6, respectively), and a third cluster containing the rest of the patients, with 30% to 50% limitation in ROM. The degree of limitation in ROM decreased after 2 weeks. Comparison of the patients in the clusters of week 0 and week 2 revealed a shift of patients within the clusters, although the number of patients in the clusters remained almost constant. CONCLUSION: Only three stable clusters could be identified, which questions the suitability of more detailed classifications, such as described by Cyriax or the Dutch Guidelines for Shoulder Complaints, for the diagnosis of patients with shoulder complaints in general practice.

A shoulder pain score: a comprehensive questionnaire for assessing pain in patients with shoulder complaints.

This study describes the validation and application of a comprehensive questionnaire (the shoulder pain score) in assessing pain experienced by patients with shoulder complaints. The shoulder pain score comprised six pain symptom questions selected from the literature, together with a 101-Numerical Rating Scale (NRS-101). The score was tested in a follow-up study of 101 patients with shoulder complaints. The coefficient for the internal consistency of the shoulder pain score was 0.82. A factor analysis disclosed two factors: one containing the NRS-101 with the "active" items of the shoulder pain score and another containing the "passive" items. The shoulder pain score gave a reliable impression of the pain experienced and proved to be a useful instrument for following the course of the disorder over time and giving an indication when a patient feels cured.

The influence of the mobility in the cervicothoracic spine and the upper ribs (shoulder girdle) on the mobility of the scapulohumeral joint.

OBJECTIVE: To examine the influence of the cervicothoracic spine and upper ribs (shoulder girdle) on glenohumeral mobility and the development of shoulder complaints. DATA COLLECTION AND SYNTHESIS: Literature was collected by a search in Medline and Embase for English, German and Dutch publications, by further checking references in the articles found and by perusal of already collected literature regarding shoulder research. Articles referring directly or indirectly to a mutually influencing anatomical connection between the cervicothoracic spine, upper ribs (shoulder girdle) and scapulohumeral joint were selected during a consensus meeting of all reviewers. RESULTS: Eight relevant articles, differing strongly in supposition and objective, were found and subsequently classified and presented according to the anatomical relations indicated in the articles. Indications were found that suggested anatomical relations between the mobility in the shoulder girdle and the scapulohumeral joint, between the mobility in the spinal column and the first rib (shoulder girdle) and between the spinal column and the scapulohumeral joint. No relevant indications regarding the development of shoulder complaints were found. CONCLUSIONS: Although no direct evidence was found, a comparison of the results of this study with theories postulated by other researchers on this subject suggests that a certain relation does exist.

Identification of an M(r) 60,000 polypeptide unique to the meiotic spindle of the mouse oocyte.

The mouse oocyte expresses an M(r) 60,000 (p60) polypeptide that is associated with the first and second meiotic spindles. Immunoreactive p60 was not detectable in the meiotic spindles of male germ cells or in mitotic spindles. P60 was identified with a polyclonal antibody whose predominant activity is directed against ankyrin. However, immunoadsorption experiments demonstrated that p60 is not an ankyrin isoform and represents a secondary activity of the polyclonal antibody. Circumstantial evidence suggest that p60 may be a microtubule-associated protein. Since the most obvious difference between the female meiotic spindle and other spindles is the long half-life of the former, we hypothesize that p60 may function in the maintenance of the long-lived female meiotic apparatus.

Organization of the membrane skeleton in spreading mouse blastomeres. I. Morphological analysis.

Differentiation in the mouse embryo begins at the 8-cell stage when the blastomeres spread against each other in a process called compaction. The spreading behavior of blastomeres on lectin-coated coverslips mimics that of blastomeres in the embryo, and we have utilized this model system to obtain an en face view of the membrane skeleton in the spreading blastomeres. Embryos were cultured on the coverslips for periods ranging from 20 sec to 6 hr, and the cells were disrupted to expose the cytoplasmic face of the adherent membranes and their associated filaments. The "membrane lawn" preparations were fixed, critical point dried, rotary shadowed, and the replicas examined by transmission electron microscopy. Using this technique we found that the plasmalemma of rounded blastomeres is associated with a lacy 3-dimensional filamentous meshwork that is transformed into a thin mat of densely woven filaments when the cells flatten. The overall organization of the membrane skeleton is similar in flattening 2- and 8-cell embryos, but there are significant differences in the time required for spreading to take place, in the means whereby the membrane skeletons are reorganized, and in the extent of maximal flattening. The significance of these observations for the compaction process is discussed.

Immunofluorescence localization of an adducin-like protein in the chromosomes of mouse oocytes.

The mouse oocyte expresses a polypeptide of Mr 120,000 that cross-reacts with an antibody to the brain membrane skeletal protein adducin. Immunofluorescence localization showed a bright chromosomal staining reaction in metaphase I and metaphase II oocytes. Following in vitro fertilization the maternal chromosomes lost their immunoreactivity during pronuclear development. The fertilizing sperm chromatin and male pronucleus did not show any detectable staining reaction. Bright chromosomal fluorescence was again observed in the first mitotic metaphase when both maternal and paternal chromosomes gave a positive staining reaction. In contrast to the immunoreactivity of the maternal meiotic chromosomes, the meiotic chromosomes of male germ line cells failed to exhibit any detectable staining reaction and this difference was confirmed by immunolabeling of oocyte and spermatocyte karyotypes. Mitotic chromosomes in preimplantation embryos, fetal liver, adult intestinal epithelium, and MDCK cells also failed to show any detectable labeling reaction. The results suggest that expression of the immunoreactive chromosomal adducin may be a unique feature of oogenesis.

Membrane-cytoskeletal interactions in the early mouse embryo.

Differentiation in the early mouse embryo begins at the 8-cell stage when the blastomeres flatten against each other by active spreading movements and surface and cytoplasmic elements become concentrated in the apical (uncontacted) region of the cells. A ring of cortical myosin marks the demarcation between the contacted and the uncontacted cellular domains. The organization of the cortical contractile apparatus in the blastomeres bears a formal resemblance to that of other cells that are engaged in similar motile activities. It has been proposed that a flow of cortical filaments could provide the motor that powers these movements. The applicability of such a cortical flow model to the early embryo and the implications for cell flattening and cell polarization are discussed in this review.

Spectrin synthesis in the preimplantation mouse embryo.

The preimplantation mouse embryo expresses two polypeptides, Mr 240,000 and Mr 235,000, that are immunologically cross-reactive with antibody to the alpha and beta subunits of mouse brain spectrin. We investigated the synthesis of the spectrin subunits in the Triton-soluble and Triton-insoluble fractions of fertilized eggs, two-cell embryos, compacted morulae, and blastocysts labeled with L-[35S]methionine. Synthesis of embryonic spectrin began in the Triton-soluble fraction with significant levels of alpha-spectrin synthesis first detected in the morula stage and significant levels of beta-spectrin synthesis detected in the blastocyst stage. Incorporation of newly synthesized alpha- and beta-spectrin into the cytoskeletal fraction took place in the blastocyst when equal amounts of both subunits were assembled. Previous studies have shown Triton-insoluble spectrin to be concentrated in regions of cell-cell contact in the embryo (J. S. Sobel and M. A. Alliegro, 1985, J. Cell Biol. 100, 333-336). The temporal and spatial correlation between the assembly of newly synthesized spectrin and its concentration in regions of cell apposition is consistent with the hypothesis that cell contact may influence the assembly of embryonic spectrin.

Spectrin and calmodulin in spreading mouse blastomeres.

The role of spectrin and its association with calmodulin in spreading mouse blastomeres was investigated. Embryonic spectrin binds 125I-calmodulin in a calcium-dependent fashion in the blot overlay technique. Double-labeling experiments show coordinate redistribution of spectrin and calmodulin in blastomeres preparing to undergo active spreading movement. At this stage cortical spectrin staining is lost from the region of cell-substrate contact and spectrin and calmodulin become concentrated in two structures closely associated with the contacted region: a group of spherical bodies located on the cytoplasmic side of the cortical layer and a subcortical ring that marks the perimeter of the contacted region. The localization pattern of spectrin and calmodulin is also coordinated with that of actin and myosin. The results suggest that spectrin plays a role in the spreading of blastomeres and that this function may involve linkage of spectrin, calmodulin, and the cortical contractile apparatus.

Changes in the distribution of a spectrin-like protein during development of the preimplantation mouse embryo.

The mouse blastocyst expresses a 240,000-mol-wt polypeptide that cross-reacts with antibody to avian erythrocyte alpha-spectrin. Immunofluorescence localization showed striking changes in the distribution of the putative embryonic spectrin during preimplantation and early postimplantation development. There was no detectable spectrin in either the unfertilized or fertilized egg. The first positive reaction was observed in the early 2-cell stage when a bright band of fluorescence delimited the region of cell-cell contact. The blastomeres subsequently developed continuous cortical layers of spectrin and this distribution was maintained throughout the cleavage stages. A significant reduction in fluorescence intensity occurred before implantation in the apical region of the mural trophoblast and the trophoblast outgrowths developed linear arrays of spectrin spots that were oriented in the direction of spreading. In contrast to the alterations that take place in the periphery of the embryo, spectrin was consistently present in the cortical cytoplasm underlying regions of contact between the blastomeres and between cells of the inner cell mass. The results suggest a possible role for spectrin in cell-cell interactions during early development.

Myosin rings and spreading in mouse blastomeres.

The relationship between myosin organization and cell spreading in the preimplantation mouse embryo was studied by indirect immunofluorescence in embryos cultured on lectin-coated substrates. Binding of cell surface polysaccharides to substrate-bound concanavalin A and wheat germ agglutinin induced changes in myosin distribution that resembled those which occur during cell-cell contact interaction. This involved an initial loss of myosin from the contact region that was associated with the development of stable cell-substrate attachments. In addition, a ring of myosin was formed along the edge of the cells' contact to the substrate. The presence of such a ring may be related to the potential for subsequent cell spreading. A myosin ring was also identified in the apical junctional region of the outer morula cells where it similarly separated the cell periphery into contacted and free peripheral domains. Following these changes in myosin organization the embryos spread on the substrate by extension of lamellipodia. These movements were coupled to the dissolution of the myosin ring and the reorganization of myosin into filament bundles. The sequence of changes in the pattern of myosin distribution suggests that contact regulation of myosin organization plays an important role in controlling the spreading behavior of blastomeres and perhaps more generally in the organization of cells into epithelia.

Cell-cell contact modulation of myosin organization in the early mouse embryo.

Preimplantation mouse embryos are characterized by a polarized distribution of cortical myosin (J. S. Sobel (1983). Dev. Biol. 95, 227-231.). Myosin was present in the peripheral regions of the blastomers and was not detectable in regions of cell contact. Disaggregation of the embryos yielded blastomeres which had a continuous layer of cortical myosin. Development of new contact relations in aggregates, between daughter cells of divided blastomeres, and in chimaeras resulted in renewed polarization of cortical myosin. The results indicate that continuous cell contact interaction modulates the distribution of myosin throughout the preimplantation stages of development. The loss of detectable myosin from regions of cell contact was correlated with development of cell contacts that remained stable after Triton X-100 extraction.

Localization of myosin in the preimplantation mouse embryo.

Myosin was localized in cytoskeletal preparations of preimplantation mouse embryos using indirect immunofluorescent techniques. Blastomeres of 2- and 4-cell embryos exhibited a continuous band of cortical myosin in their apical borders while no cortical myosin was detectable in regions of cell apposition. In 8-cell, 16-cell, and advanced morula-stage embryos the outer group of cells was also characterized by a continuous apical band of cortical myosin, whereas the inner group of apposed cells usually showed no detectable cortical myosin. The possible significance of these observations is discussed.